Outcomes Of Combined Rheolytic And Rotational Mechanical Thrombectomy For Total Access Circuit Thrombosis In Hemodialysis Patients Nicholas Petruzzi, MD Raphael Cohen, MD Mark Mantell, MD Timothy W. Clark, MD University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA
Disclosures Personal None Co author Royalties Merritt, Teleflex
Background Percutaneous thrombectomy is the standard of care for most patients with hemodialysis access thrombosis In a subset of patients, the entire access circuit from arterial anastomosis to central venous system is thrombosed
Background Most commonly employed approach to total access thrombosis is placement of a multisidehole infusion catheter and 1 2 day pharmacologic thrombolysis using TPA This is due to theoretical risk of large clot burden producing symptomatic PE
Background Thrombolysis is not without its own risks Typically requires 24 48 hours of infusion Requires careful ICU monitoring and neuro checks Costs associated with longer hospitalization Risk of death or intracranial bleed 0.3% 1 Risk of major bleeding 8% 1 Vedantham S et al. JVIR 2006
Purpose To examine the outcomes of combined rheolytic and rotational mechanical thrombectomy for total access thrombosis patients versus control declots
Methods Prospective QA database identified 25 total access thrombosis out of 350 declots over 3 year period These cases were matched at a 1:3 ratio to a control group of 75 patients with thrombosis of the access only 350 Declots over 3 year period 25 patients with total access thrombosis Matched at 1:3 ratio to control declots (access clotted only)
Methods Total access thrombosis cases underwent mechanical thrombectomy in central veins with rheolytic device (Angiojet DVX) then rotational device (Arrow Trerotola PTD) within access
Total Access Thrombosis
Access only thrombosis (controls) underwent mechanical thrombectomy with a single device (Arrow Trerotola PTD) Methods
Methods Baseline characteristics between groups compared Outcomes compared Technical Success Clinical Success At least 1 successful HD treatment Median Patency Censored at time of re thrombosis, transfer of care, or new access creation Fluoroscopy Time Proxy of procedural complexity
Results - Demographics Control Total Thrombosis P Value Type of Access (graft:fistula) 63:12 21:4 1 Age 64 66 0.66 Race (B:W) Gender (M:F) Side of Access (L:R) 71:4 24:1 0.79 41:34 13:12 0.82 59:16 18:7 0.49
Results - Outcomes Control Total Thrombosis P Value Technical Success 95% 92% p=0.63 Clinical Success 94% 88% P=0.39 Fluoroscopy Time 13.6 min 24.5 min p<0.01 Median Patency 123 days 75 days p=0.71
Results
Results 90 day patency rates were 40.1% for total venous thrombosis group compared to 56.2% for the control group K/DOQI recommended threshold is 40% at 3 months
Complications One episode of bradycardia and hypotension occurred in the total thrombosis group Resolved with sedation reversal Two axillary vein ruptures after angioplasty One successfully treated with balloon tamponade Other successfully treated with stent graft placement No bleeding complications or documented PE
Limitations Retrospective study design Single center Sample size
Conclusions Total access circuit thrombosis was a salvageable failure mode with post intervention primary patency rates not significantly different than controls Both groups exceeded the KDOQI recommended threshold of 40% patency at 3 months 2 National Kidney Foundation. Am J Kidney Dis 2002.
Conclusions Higher procedural complexity in the total access thrombosis group resulted in significantly longer fluoroscopy times Further work needed to compare costs of additional thrombectomy device vs. ICU stay/lytic infusion
References 1. Vedantham, Suresh, et al. "Quality improvement guidelines for the treatment of lower extremity deep vein thrombosis with use of endovascular thrombus removal." Journal of vascular and interventional radiology 17.3 2006: 435 448. 2. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 (suppl 1)):S1 S266. 3. Shatsky, Josh B., et al. "Single center experience with the Arrow Trerotola percutaneous thrombectomy device in the management of thrombosed native dialysis fistulas." Journal of vascular and interventional radiology 16.12 2005: 1605 1611.